Septic arthritis of the knee following anterior cruciate ligament reconstruction

Jabalameli, Mahmoud; Rahbar, Mohammad; Hadi, Hosseinali; Radi, Mehran

Mahmoud Jabalameli¹

, Mohammad Rahbar²

, Hosseinali Hadi³

, Mehran Radi⁴

1- Associate Professor of Orthopedic Surgery, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.
2- Assistant Professor of Orthopedic Surgery, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
3- Assistant Professor of Orthopedic Surgery, Department of Orthopedic Surgery, Arak University of Medical Sciences, Arak, Iran
4- Orthopedic Surgeon, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.

Keywords: Septic arthritis, Anterior cruciate ligament, Reconstruction, Infection

Full-Text [PDF 232 kb] (690 Downloads) | Abstract (HTML) (1065 Views)

Full-Text: (349 Views)

Abstract

Methods: Ten patients with knee joint infection after anterior cruciate ligament reconstruction were enrolled. Demographic data and information related to the surgical technique were collected. Onset time from index procedure, clinical and laboratory findings, interval between onset of symptoms and first debridement, number and type of operations were recorded. The latest status of patients and the relationship between onset time of symptoms with final results and also time interval between onset and debridement with the final results were also studied.

Results: Ten patients, all male, mean age 25(19-31) years, were followed for an average of 33 (18-112) months. Four patients had acute infection, 5 subacute and the remained one chronic infection. In subacute and chronic infections, patients often had not systemic symptoms. For each patient 2.3 times of joint debridement and lavage were performed. The graft was removed in 50% of cases. Increased erythrocyte sedimentation rate (ESR) and C – reactive protein (CRP) levels and synovial fluid polymorphonuclear (PMN) cells count were highly helpful in the diagnosis. Joint fluid culture was positive in 40% of the patients. In the latest survey, 20% had pain with vigorous activity, 30% had symptoms of instability and 20% had limited knee range of motion.

© 0, Shafa Orthopedic Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

Infection following anterior cruciate ligament (ACL) surgery is an uncommon but potentially serious complication. The relevant literature consists of few series with small numbers of patients treated with management protocols ranging in aggressiveness from arthroscopic irrigation to radical debridement with graft and hardware removal (1). The prevalence of infection following ACL reconstruction is very low and ranges from 0.14% to 1.74% (2, 3). Overall, septic arthritis following ACL surgery was caused by staphylococcal species in vast majority of cases (88%) (3-6). The diagnosis may not be easy and classic signs of knee sepsis can be masked by postoperative changes (7, 8).

Because of the small number of reported cases, it is difficult to determine risk factors, the success of different treatment options, and treatment results. However, optimal clinical management guidelines have not been completely established. Published recommendations have differed on graft retention, open versus arthroscopic treatment, type and duration of antibiotics, and time to revision (3-6, 9). While some authors recommend to remove the graft immediately (3, 4, 10), others remove the graft only in case of persistent infection (5).

Array

2. Methods

3. Results

4. Discussion

Array

Local risk factors for infection include previous knee surgery or concomitant surgical procedures performed during initial ACL reconstruction, reconstructions with hamstrings graft, concomitant or previous meniscal repair, the use of a post and washer fixation of the graft on the tibia or the Endobutton femoral tunnel fixation were associated with increased risk of intra-articular infections (4, 12-14). In this study all of these factors were present and three patients had concomitant procedures with ACL reconstruction (one meniscal repair, one microfracture for cartilage lesion and one high tibial osteotomy). However, the role of secondary procedures in development of infection is not clear, as the existing studies have not performed a comparison between infected and control patients. Contamination through the surgical incision or the arthroscopic portals at the time of ACL reconstruction may be the most probable cause of an acute infection (6).

Array

Elevated CRP has been invariably reported in patients with ACL postoperative infections; the mean CRP levels ranged from 2.6 to 12.3 mg/dl in the previous studies. Elevated levels of ESR have been similarly reported in the literature, with mean values ranging from 48 to 87 mm/hr (6, 14-16). Mean ESR and CRP levels were 83.4 mm/hr and 24 mg/dl in our study, respectively. Margheritini et al. (8) reported that CRP returns to nearly normal levels by postoperative day 15, which was faster than the ESR. Elevated levels of CRP beyond the postoperative day 15 or any secondary rise strongly point toward a septic etiology for the patient's symptoms. The authors concluded that the CRP is a more sensitive indicator of postoperative septic complications (7, 11, 17).

Array

Positive synovial culture was reported between 14- 82% (16, 17). Several micro-organisms are reported as causative agents, such as Staphylococcus aureus (most common cause), coagulase-negative Staphylococcus, or rarer agents like nonhaemolytic Streptococcus, Peptostreptococcus, Enterobacter species, and other anaerobic or gram-negative organisms (3-6). Many cases of persistent septic knee arthritis are polymicrobial (2, 3, 12, 16). In our study synovial culture was positive in 4 cases in which two were Staphylococcus species.

Array

5. Conclusion

Acknowledgements

References

1. Schollin-Borg M, Michaelsson K, Rahme H. Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy. 2003; 19(9): 941-7[PubMed]
2. Fong SY, Tan JL. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Ann Acad Med Singapore. 2004; 33(2): 228-34[PubMed]
3. Indelli PF, Dillingham M, Fanton G, Schurman DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2002; (398): 182-8[PubMed]
4. Williams R3, Laurencin CT, Warren RF, Speciale AC, Brause BD, O';Brien S. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management. Am J Sports Med. 1997; 25(2): 261-7[PubMed]
5. Musso AD, McCormack RG. Infection after ACL reconstruction: what happens when cultures are negative? Clin J Sport Med. 2005; 15(5): 381-4[PubMed]
6. Zalavras CG, Patzakis MJ, Tibone J, Weisman N, Holtom P. Treatment of persistent infection after anterior cruciate ligament surgery. Clin Orthop Relat Res. 2005; 439: 52-5[PubMed]
7. Johnson MW. Acute knee effusions: a systematic approach to diagnosis. Am Fam Physician. 2000; 61(8): 2391-400[PubMed]
8. Margheritini F, Camillieri G, Mancini L, Mariani PP. C-reactive protein and erythrocyte sedimentation rate changes following arthroscopically assisted anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2001; 9(6): 343-5[DOI][PubMed]
9. Van Tongel A, Stuyck J, Bellemans J, Vandenneucker H. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med. 2007; 35(7): 1059-63[DOI][PubMed]
10. Blevins FT, Salgado J, Wascher DC, Koster F. Septic arthritis following arthroscopic meniscus repair: a cluster of three cases. Arthroscopy. 1999; 15(1): 35-40[DOI][PubMed]
11. Monaco E, Maestri B, Labianca L, Speranza A, Vadala A, Iorio R. Clinical and radiological outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. J Orthop Sci. 2010; 15(2): 198-203[DOI][PubMed]
12. Burks RT, Friederichs MG, Fink B, Luker MG, West HS, Greis PE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med. 2003; 31(3): 414-8[PubMed]
13. McAllister DR, Parker RD, Cooper AE, Recht MP, Abate J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med. 1999; 27(5): 562-70[PubMed]
14. Judd D, Bottoni C, Kim D, Burke M, Hooker S. Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 2006; 22(4): 375-84[DOI][PubMed]
15. Viola R, Marzano N, Vianello R. An unusual epidemic of Staphylococcus-negative infections involving anterior cruciate ligament reconstruction with salvage of the graft and function. Arthroscopy. 2000; 16(2): 173-7[PubMed]
16. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007; 297(13): 1478-88[DOI][PubMed]
17. Matava MJ, Evans TA, Wright RW, Shively RA. Septic arthritis of the knee following anterior cruciate ligament reconstruction: results of a survey of sports medicine fellowship directors. Arthroscopy. 1998; 14(7): 717-25[PubMed]
18. Gristina AG, Costerton JW. Bacterial adherence and the glycocalyx and their role in musculoskeletal infection. Orthop Clin North Am. 1984; 15(3): 517-35[PubMed]
19. Mouzopoulos G, Fotopoulos VC, Tzurbakis M. Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2009; 17(9): 1033-42[DOI][PubMed]
20. Binnet MS, Basarir K. Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques. Arthroscopy. 2007; 23(8): 862-8[DOI][PubMed]

Subject: Knee surgery
Received: 2019/09/9 | Published: 2014/05/15

Rights and permissions
	This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.